Clinical trial results show stark disparities in use of life-saving implantable cardiverter defibrillator (ICD) interventions based on sex and race, suggesting potential bias in care pathways to electrophysiologists (EP). Dr Anne B Curtis discusses her recent study presented at HRS 2020 in an expert interview.
Q. What were the aims and design of your recent study?
There are known disparities in the use of guideline-indicated device therapy ICDs and cardiac resynchronization devices (CRT-D) by sex and race. We wanted to see if consultation with an EP, a specialist in the treatment of heart rhythm disorders, would mitigate those differences and simply treat patients according to guidelines without regard to sex or race. We used a national Electronic Health Record database curated by Optum that has 2.9 million de-identified patient records in it. By using a process called computable phenotypes, we were able to query all the records in the system in a short time, which would be impossible if we were to go through each record manually.
Q. What percentage of people who meet the criteria, actually receive ICDs?
Of the patients who met secondary prevention indications (had already survived a potentially-life threatening arrhythmia), 41% received ICDs. For primary prevention (patients at risk but have not yet had a potentially life-threatening event), only 8.3% received ICDs.
Q. In which patients could an ICD be used for primary prevention? What percentage of these patients receive an ICD?
If you group all patients who are indicated for an ICD, 11% overall received one.
Q. What were the findings the study in terms of sex and race?
Among 159,099 patients with an indication for a device, 54.7% of men and 51.2% of women saw an electrophysiologist (p<0.001). Among the 84,943 patients seen by an electrophysiologist, 28.1% of men and 23.0% of women received an ICD (p<0.001). By rate, 55.5% of whites and 46.9% of other races saw an electrophysiologist (p<0.001). Among the patients seen by an EP, 25.9% of whites and 27.9% of others received an ICD. (p<0.001) (This is not a typo – fewer whites received devices than others.)
Q. What can be done to overcome these deficiencies and disparities?
Continuing education to shine a light on these differences and make providers aware to watch out for unconscious bias. Quality improvement programs in hospitals and outpatient practices can help as well.
Support: Commissioned, developed and supported by Touch Medical Media.
Published: 15 May 2020
